The authors prospectively studied 106 consecutive phakic eyes with acute posterior vitreous detachment to determine the correlation between anterior vitreous pigment granules and retinal breaks. Pigment granules were identified in 15 eyes (14.1%), all of which had either a flap or an operculated retinal break. A retinal tear was found in only one eye without pigment granules (P = 0.000). Other factors demonstrating a statistically significant association with retinal breaks included grossly visible preretinal or vitreous blood (P = 0.039) and male gender (P = 0.000). In the absence of other ocular pathology, the presence of vitreous pigment granules identifies a very high-risk group of acute posterior vitreous detachment patients.